EGS Co-Funded Marketing for Educational Events Request

EndoGastric Solutions is committed to working with our customers to build awareness of and interest in the TIF procedure for treating chronic acid reflux disease. In this spirit, the Company will help share costs for educational events and promotional campaigns that spread awareness about GERD symptoms, diagnosis and treatment options, including the TIF procedure. To begin the approval process for co-funded marketing, please fill out this form as completely as possible.

Question Title

* 1. Please enter the name of the primary TIF trained physician.

Question Title

* 2. What is the name of the practice or hospital?

Question Title

* 3. Please enter name and other information of the site contact associated with this request. Please use a business address.

Question Title

* 4. Notice: Reimbursements are documented and reported per Federal, Sunshine Act Regulations. For this reason, please provide the Physician’s National Provider Identifier Number (NPI#) and State License number.

Question Title

* 5. What is the name of your EGS sales representative?

Question Title

* 6. Are you promoting the TIF procedure via social media? If so, please provide the information below. We would like to link with you whenever possible.

Question Title

* 7. Is this campaign being performed to solely promote an individual physician, practice or facility without discussing TIF?

T